HABITS: Adequate exercise . Unknown woe ¢ *& &#® # @ = m More QO = Sleep well... . se ee Bowels move regularly . Diet well balanced. .... Fruit servings per day .. Vegetables per day. Eogs per day. . ... ae Bread, slices per day . Potato servings per day . Cereal servings per day. . e * * a . e¢ * &* TTT ELE Meat servings per day. NOTE: Diet for an average day. # Milk, glasses per day . Coffee, cups per day Tea, cups/glasses per day . Soft drinks per day . Water, glasses per day Salt used _little . moderate “much . * * . Spices, pepper, pickTes, etc much moderate little Alccholic beverages none __rarely __moderatelydaily Tobacco: Cigarettes, pks per “ay Cigars .. . 2... Pipe .. : see ws _ Chewing tobacco eee ee SNUff 2. ow ww we ee * . . * ° * . ¢= 8®© @® &®& Drugs: Laxatives .. . 2 « s Vitamins Sedatives ... ‘ Tranquilizers ... sleeping pills... Aspirin. . Cortisone, Acth . Thyroid... se as ‘Appetite depressants. Treatment for drug habits . Insulin. ... os Tablets for diabetes. Hormone shots or tablets. Other (please specify). . . Work: Hours per day = 8 4 or less 8 & &@ 8 @® we # es &€ @ © ee & w@ 4 or more Indoors & wp © «4 8 9 or more